Healthcare Provider Details

I. General information

NPI: 1790326080
Provider Name (Legal Business Name): MR. MATTHEW R LAKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 E 11 MILE RD
WARREN MI
48092-2878
US

IV. Provider business mailing address

3601 E 11 MILE RD
WARREN MI
48092-2878
US

V. Phone/Fax

Practice location:
  • Phone: 303-989-8169
  • Fax:
Mailing address:
  • Phone: 303-989-8169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401003468
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: